Crisis demands better treatment options
Addicts face uphill road to recovery, but hope beats strong
By Waylon Cunningham
Adams Publishing Group
Sunday, May 12, 2019
Tucked between a barber shop and an antiques store along a dark highway into Knoxville, Tennessee, the Flatiron Club is easy to miss driving by at night. Its only announcement, completely invisible in the dark, is a small, unlit sign above the door.
Inside, two older men and a woman holding a Styrofoam cup loiter in the fluorescent-lit space. A nearby foldout table and chairs sit unused. A young man, thick-armed in a tight black shirt, walks in.
“Sorry,” an older man tells him, “the meeting’s been canceled — the organizers got sick, no one came.” Then he pauses to reconsider. “Pull up a chair,” he says.
Seated around the table meant for a much larger group, the four are quiet at first. The young man, though he’s normally reserved, begins to speak.
“Hi, my name is David,” he says, “and I’m an addict.”
Then the room, white and sterile-looking, comes alive with stories of struggle and redemption.
David Wilson, a 27-year-old from a struggling community on the Kentucky border, is one of the 1.7 million people in the United States with an opioid abuse disorder, as estimated by the American Addiction Centers. Clean now for nearly three years, Wilson tries to attend at least four meetings a week, more than his halfway house requires. And while the meeting at the Flatiron Club is not even for opioids — it’s technically a Crystal Meth Anonymous group — there is an understanding among the recovery community that the actual drug doesn’t matter, as long as you’re attending meetings.
And you’d better be attending meetings.
For years, those wading through the long process of addiction have found relief in support groups based on the 12-step Alcoholics Anonymous program. “The therapeutic value of one addict helping another is without parallel,” goes an often-repeated line from the Narcotics Anonymous handbook.
But there’s another reason these discussion groups play such a central role. Few other resources are available at all for those in long-term recovery.
While public awareness about addiction has grown in recent years as the opioid crisis deepened, the solutions offered by policymakers and nonprofits are often weighted toward what is, for many addiction stories, only the opening act.
To try to stop addiction before it happens, 15 states stretching from Utah to South Carolina have placed strict limits on painkiller prescriptions. High school educational drives are intended to warn students away from abuse. And for those in the throes of addiction, emergency services have begun to stockpile naloxone, an overdose-reversing drug.
But for everything that comes after the active addiction, attention and funding peter out.
LAWS SLOWLY CHANGING
The continuing stigma surrounding addiction is a large impediment, says Steve Wildsmith, a recovery advocate in the marketing department of Cornerstone of Recovery, an intensive residency program in Louisville, Kentucky.
While many states have laws mandating that insurance plans include addiction-treatment coverage, the majority will pay "at most" for 28-day rehab programs, Wildsmith says.
Physical healing of the brain takes much longer — up to 10 years for sustained remission, according to 2017 statistics from the National Institutes of Health. Meanwhile, about 4 percent of the opioid-addicted population dies annually of overdoses.
But this approach is beginning to change.
“There’s been a growing realization that this is a lifelong, chronic disease,” said Karen Pershing, executive director of the Metro Drug Coalition, an anti-addiction nonprofit partially funded by the City of Knoxville.
As data continues to show a worsening crisis, groups like the American Psychiatric Association have adapted. In 2013, the APA updated the DSM, the standard diagnostic manual for clinicians of mental disorders, to convey the new understanding of addiction as chronic and those who suffer from it prone to relapse.
Solutions have begun to follow suit.
Massachusetts’ 2018 opioid legislative package, signed by Gov. Charlie Baker at the STEPRox Recovery Support Center in Boston, focuses the bulk of its efforts on improving access to treatment and expanding the role of recovery coaches. It creates new pathways connecting hospital emergency rooms to inpatient treatment programs, creates a commission studying the efficacy of these programs and lays the groundwork for pilot programs in five corrections facilities across the state to offer medication-assisted treatment.
In Minnesota, initiatives like the Minnesota Recovery Corps, a new offshoot of the national service organization AmeriCorps, recruits volunteers to be “recovery navigators.” These navigators — often drawing from their own experiences with the disease — mentor those working to overcome opioid addiction and help them find resources.
“Minnesota has done a really good job,” said Mark Pew, senior vice president of Louisville-based Preferred Medical and a 20-year expert on opioids. “They’ve got a dashboard that talks in terms of statistics, and did treatment guidelines for the entire state last year.”
SERVICES OFTEN SCATTERED
A lingering problem facing many efforts to help those in recovery, such as assistance with housing or re-acquiring a driver’s license, is that they are scattered, Pershing said.
“Right now, you just have to try to find them on your own,” she said.
Her organization is seeking to create a resource recovery center to centralize this kind of information. They are taking note from longtime existing facilities like the Council on Recovery in Houston, which not only gathers many recovery services under one umbrella, but connects clients and walk-ins to available outside resources, as well.
In some areas, local governments are leading the charge. Blount County, just south of Knoxville, has, in recent years, put increasing emphasis on its Recovery Court program (recently renamed from Drug Court), which diverts drug offenders from the jail into a strictly regimented curriculum to get them clean. For many in the program, it is the first help from mental health professionals they have ever received.
Blount County Judge Tammy Harrington said she has seen even hardened, long-term offenders emerge with a lasting grip on sobriety. Daniel McQueen, who had been in and out of the jail many times but is now “addicted to recovery,” with dreams to establish a recovery center of his own, is just one example.
While addiction is a powerful disease, it is not damning.
Living proof is found in the recovery stories of those like Christopher Russell, who after years spent in the deepest pits of addiction following a traumatic childhood, is now working toward a bachelor's degree in counseling psychology.
Pam Spindel spent years on the street, but in February earned a pardon from the Tennessee governor for her addiction-related crimes.
Steve Wildsmith became an award-winning newspaper columnist. Today, all three work at Cornerstone of Recovery, helping those still early in their recovery process.
And the victories from sobriety also come in much simpler forms. Just ask Wilson, the young man at the Flatiron Club meeting.
“I’m the happiest I’ve been in my entire life,” he says.
This is the second of three parts in a series by Adams Publishing Group newspapers about the nation's ongoing and evolving opioid crisis. The first segment was published May 5 and the third will run May 12. Visit this piece on reflector.com to see related stories.
Part 1 addressed the magnitude of the problem across the country as well as its causes and impacts.
Part 2 looks at treatment options for people addicted to opioids and the availability of those services.
Part 3 assesses policies state and local governments are pursuing to stem the epidemic.
Flipping the Script – attacking the opioid crisis
Who would argue with the goal of wanting to treat pain adequately? That’s where the opioid crisis started.
Opioids are different from the other addiction crises we have faced over the decades — crack, meth, cocaine and alcohol. Compared to these substances, opioid overdoses are more likely to be fatal. And medical providers, the pharmaceutical industry and our systems are implicated in the causes of the opioid crisis.
We all bought the line, patients and providers alike – we were neglecting our patients if we did not eradicate their pain completely. Many moved from treating acute pain effectively with opioids to using these powerful drugs to treat ongoing chronic pain. Data is sorely lacking for the latter approach.
Prescription opioids are an important treatment option for acute pain and end-of-life pain. However, opioids are a lousy treatment for chronic pain. In the middle of this crisis, we have learned how complex pain is. It includes physical trauma from injuries or surgeries, along with what each person brings, such as cultural trauma, depression, anxiety or fear of pain.
Better alternatives to ongoing opioids include physical therapy, complementary medicine, and non-opioid medications. These, combined with carefully working to lower opioid doses, are very often effective.
What can we do to wrestle this monster to the ground? Our approaches fall into three categories: preventing addiction, responding to emergency overdoses, and treating addiction.
To prevent addiction, we aim to limit initial prescribing of opioids to just enough for the worst, most acute pain. For surgery, sometimes just talking about the patient’s expectations beforehand can reframe the pain from abnormal to an expected part of the healing process.
In Minnesota, we are working with prescribers, first gently, then firmly, to let those who are too loose with opioids know that they are causing harm. Other states could do the same.
We developed Minnesota’s opioid prescribing guidelines in partnership with the medical community. Doctors receive individualized reports allowing them to compare their prescribing practices with those of similar providers. Those who continue to prescribe outside the guidelines get help, then are asked to improve. If the situation warrants, they could lose their ability to serve patients on Medicaid. We are careful to look at unique situations.
These efforts are already working. In Alexandria, Minnesota, a woman who had taken prescription opioids for pain for about 20 years worked with her doctor to reduce her use. After years of feeling hungover, she can now play with her grandchildren and remember what they tell her. Hundreds like her are flipping the script of chronic opioid use.
To help providers, our new Flip the Script outreach program arms health care professionals with the tools and resources to talk with their patients about opioids and pain management.
To protect people who are taking high levels of opioids for chronic pain or who have become addicted to opioids, we want them to stay safe and engaged. All lives have value. It’s essential we ensure the availability of naloxone, the opioid overdose reversal drug, and get it to those who need it. We cannot let judgment about opioid use limit action.
To treat those with substance use disorder, we need to take away the stigma. We need to see it as a disease that can be treated, including with medications.
Access to medication-assisted treatment, provided close to home by local treatment professionals and linked to behavioral health support, is the best way to help millions who suffer from opioid addiction. We are building this capacity in Minnesota and other states. Many providers want to help, and we are supporting them in this new, sometimes difficult work.
The opioid crisis calls for compassion and grit. It won’t always be comfortable — some will be afraid their pain will return. We will fear for the safety of people who relapse during addiction treatment. Still, when we show compassion, those on the edge are more likely to accept the grit. And when our patients, family members and friends return from this very hopeless place, there will be no better reward.
Together, we can flip the script. We can tackle this crisis, support each other and end up with stronger, healthier communities.
Dr. Jeff Schiff is the Minnesota Department of Human Services’ medical director for Medicaid. He leads the state’s Opioid Prescribing Improvement Program, which includes a multi-disciplinary group working to set standards for opioid prescribing in Minnesota, educational resources for doctors to use in communicating with patients about pain and opioids, and reports to providers about how their prescribing compares to their peers’.